Trauma, Reconstruction and Urethral Stricture Disease
Core concepts
Trauma questions test immediate priorities and the distinction between blunt and penetrating, and between anterior and posterior urethral injury.
Renal trauma: most blunt renal injuries are managed non-operatively. Know the AAST grading and the indications for intervention (haemodynamic instability, expanding haematoma, arterial injury). Trap: operating on a stable grade III injury.
Ureteric trauma: often iatrogenic during pelvic surgery; presents with leak or hydronephrosis. Repair depends on level and mechanism.
Bladder trauma: extraperitoneal vs intraperitoneal rupture; intraperitoneal rupture requires surgical repair, extraperitoneal can often be managed by catheter drainage.
Urethral injury: posterior urethral injury is associated with pelvic fracture and presents with blood at the meatus, perineal haematoma and retention. Do not catheterise; perform a retrograde urethrogram. Anterior urethral injury is associated with straddle injury. Trap: attempting catheterisation in suspected urethral injury.
Stricture disease: distinguish bulbar (often inflammatory or idiopathic) from penile and from posterior strictures. Know that urethroplasty is superior to repeated dilatation or internal urethrotomy for recurrent strictures, and that lichen sclerosus is an examinable cause of anterior stricture and should not be managed with repeated instrumentation.
Worked rule of thumb
A man with a pelvic fracture, blood at the meatus and retention: retrograde urethrogram first, suprapubic catheter if needed. The trap answer is "gentle urethral catheterisation".
Exam traps
- Catheterising a suspected urethral injury.
- Operating on stable renal trauma.
- Confusing intraperitoneal and extraperitoneal bladder rupture.
- Repeating urethrotomy instead of urethroplasty in recurrent stricture.